Waverley Care Home

Waverley Care Home is a large 3 story building. The service supports people with nursing needs. The service is registered to accommodate up to 20 people. At the time of the inspection, there were 11 people living at the home.

People’s experience of the service and what we found

We found high level concerns with regards to the premises and the equipment. Most areas of the home required repairs and some areas potentially put people at risk of significant harm. Hot water temperatures in sinks in people’s rooms and bathrooms were running above the required temperature, and fixtures and fittings, such as curtains in bedrooms, and paintwork, was in a poor state of repair. The dining room was not being used for its intended purpose and was being used as a storeroom. This meant people only had access to one communal area.

There was limited oversight regarding any maintenance work. Actions issued from a legionella risk assessment in March 2023 had not been completed, and there was no one checking maintenance jobs had been reported or actioned. Some records required improvement, there was no organised system to track and monitor DoLS applications, which meant that we could not be sure if DoLs had been applied for appropriately for people. There was no incident and accident analysis taking place, which meant we could not always be certain mitigation had taken place as a result of incidents. Therefore, we could not be sure lessons had been learnt from shortfalls in care provision.

There had been some improvements since the last inspection in relation to clinical care plans and medication. The provider had also made some improvements in relation to fire safety and staffing at the home.

People were looked after and staff were observed to care for people. However, due to there being a lack of space, because the dining room was not being used for its intended purpose, the home felt institutionalised in its approach. The dining experience was poor and the food was not presented nicely and did not look appetising.

People were mostly supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, some records in relation to DoLS required improving.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Inadequate, published 15 December 2022. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

When we last inspected Waverley Care Home on 27 October and 1 November 2022 breaches of legal requirements were found. We also issued a warning notice. This inspection was undertaken to check whether they were now meeting the legal requirements and to follow up the warning notices. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to infection prevention control, premises and equipment, records and governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Waverley Care Home is a large three-story building. The service supports people with nursing needs. The service is registered to accommodate up to 20 people. At the time of the inspection, there were 16 people living at the home.

People’s experience of using this service and what we found

At this inspection, we found concerns with the management of risk, medicines, record keeping, staffing, the environment and governance.

Staff did not have sufficient guidance to provide safe and appropriate care. Medication management was unsafe and placed people at risk of avoidable harm. The environment was in need of significant refurbishment and improvements were needed to ensure the safety of people living in the home.

Staffing levels were not sufficient to ensure the upkeep of the home and the safety of people at nighttime. Staff had not received a robust induction or supported with the appropriate training, however they had received regular supervision.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Care plans and risk assessments were not completed appropriately; staff did not have the most up to date information to provide safe and effective care to people living in the home.

The provider did not have sufficient oversight of the service. Quality checks and audits were not driving improvement and had not identified the issues found during the inspection. We could not be certain that complaints had been investigated appropriately as the recording was insufficient.

People were comfortable in the presence of staff and we observed staff respecting the privacy and dignity of those needing support with their care.

Rating at last inspection and update: The last rating for this service was requires improvement (published 29 October 2019) and there was a breach of regulation. At this inspection we found the provider remained in breach of regulations.

The service is now rated inadequate. This service has been rated requires improvement for the previous four consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received regarding fire safety. A decision was made for us to inspect and examine those risks. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management, medicines, environment, need for consent, staffing and governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice:

• Staff were wearing and disposing of used personal protective equipment (PPE) safely and in line with the relevant national guidance.

• The home had a robust testing programme in place to frequently test staff and people living at the home. The approach and frequency of testing had been informed by the findings of a pilot study in the local area.

• Staff at the home ensured any staff and people living at the home were appropriately supported to self-isolate when necessary.

• The home was clean and hygienic. There were cleaning schedules in place ensuring frequent cleaning took place throughout the day and staff were clear on their responsibilities regarding cleaning.

• Staff at the home had sought and responded to further advice and guidance on effective infection prevention and control practice from relevant professionals, such as the local infection prevention and control team.

Further information is in the detailed findings below.

People’s experience of using the service

At our last inspection in February 2019 the registered provider was in breach of regulations in relation to safe recruitment, consent, governance and person-centred care. We found during this inspection that the service had taken action to meet most of these breaches, however remained in breach of regulations in relation to governance.

Records were poor in quality in some areas and not always accurate, fully completed or reviewed. We also saw that some audits required improving as they had not highlighted some of the concerns during our inspection, and some audits, in relation to care plans, were not taking place. There was a manager in post who had registered with the Care Quality Commission. Staff had team meetings and people told us they felt engaged with and they liked the registered manager.

It was difficult to tell from the records if staff training was in date. We saw gaps in the training matrix in relation to some subjects the registered provider had deemed mandatory. After viewing some certificates, observing and speaking to staff, we saw evidence staff were trained. There was an ongoing plan in place to improve this which the registered manager and deputy manager have shared with us.

We observed mostly kind and caring interactions from staff, however some care plans did not always reflect what staff were doing and did impact on the caring domain in this report. People did tell us they liked the staff and felt they were kind.

Complaints were dealt with in accordance with the organisation’s complaints procedure, people said they knew how to complain. People were supported to engage in activities in the home and in the community.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The last rating for this service was requires improvement (published 27 March 2019)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found that even though some improvements had been made, in some areas enough improvement had not been made and the provider was still in breach of regulation.

The last rating for this service was requires improvement. The service remains rated requires improvement. This service has been rated requires improvement for the sixth consecutive time.

Why we inspected

This was a planned inspection in line with our methodology.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected Waverley Care Home on 12 and 13 February 2018 and gave it an overall rating of ‘requires improvement’. During that inspection we found that the home was in breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, because the home’s approach to assessing people’s mental capacity was poor and was not in line with the principles of the Mental Capacity Act 2005 (MCA) and the associated DoLS.

During this inspection we found breaches of Regulations 9, 11, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure that each person received appropriate person-centred care and treatment that was based on an assessment of their needs and preferences. Mental capacity assessments were not consistently recorded in people’s care plans and best interests meetings had not been held as needed. The provider did not have effective systems in place to monitor and improve the quality of the service. The provider had not carried out the required checks before new staff were employed.

During the inspection we found enough staff on duty to meet people’s needs and the staff we spoke with considered that staffing levels were adequate. We looked all around the home and found that it was clean and adequately maintained. Safety certificates demonstrated that utilities and services had been tested and maintained. People’s medication was stored and handled safely, however more detail was needed regarding the administration of medication prescribed to be given ‘as required’.

The registered manager introduced a new training system in 2017 but training records showed a poor level of take up of the new training packages. We saw records of regular individual staff supervisions and appraisals with the manager, but not always follow ups where improvements to practice had been identified. Monthly staff meetings were held.

People we spoke with told us they enjoyed their food and drinks at the home and we observed that drinks were offered regularly. Improvements were needed to the meals service to ensure that people received food at a safe temperature and at appropriate intervals.

One of the activities organisers brought in daily newspapers for people and supported people to go out regularly to local leisure activities, a gym, shops, cafes, and Sefton Park. Our observations in the lounge during the morning showed that people were able to express themselves and we saw friendly and cheerful interactions between people who lived at the home, and between them and the staff.

We saw that confidential information about people was stored securely in the nurses’ office which was locked when not in use.

Care plans did not adequately documents people's care and support needs or their personal choices and preferences.

This unannounced comprehensive inspection took place on 12 and 13 February 2018.

We last inspected the home in March 2017 and gave it an overall rating of ‘requires improvement’. On that inspection we found breaches of regulations 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that people may have been deprived of their liberty unlawfully; there were poor recruitment checks, inadequate staffing levels and the premises were not kept safe; there was poor governance at the service to ensure safe and effective care was being delivered and not all staff were suitably trained to meet people’s needs.

During this inspection we found that the home remained in breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This is because the home’s approach to assessing people’s mental capacity was poor and was not in line with the principles of the Mental Capacity Act 2005 (MCA) and the associated DoLS. However, we found that the home was no longer in breach of regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as improvements had been made in these areas.

For services rated Requires Improvement on one or more occasions, we will take proportionate action to help encourage prompt improvement. Regulation 17(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires a provider to give us information – when we ask them to do so - about how they plan to improve the quality and safety of services and the experience of people using services. You can see what action we told the provider to take at the back of the full version of the report.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home lacked a clear and robust approach to meet the requirements of the MCA and the associated DoLS. The staff we spoke with demonstrated a basic understanding of the principles of the MCA and the associated DoLS and they had recently received training in this area. DoLS applications had been submitted to the local authority for authorisation and there was a system in place to monitor and renew them when needed. However, we saw that several of the mental capacity assessments in people’s care files were unsigned, undated, had no plan to review the assessment. These assessments did not involve the people being assessed, their families, any independent advocates or any relevant health professionals, nor were they supported with best interests decisions. This meant that the home was not acting in line with the principles of the MCA and people living there were not being supported to live their lives in the least restricted ways possible.

The home had introduced a new training system since our last inspection, which included improved records and monitoring of staff training. However, the home did not have a formal and consistent induction process for new staff.

The people we spoke with told us they enjoyed the food and drink at the home. However, we found that not everyone’s dietary preferences were catered for.

People living at the home had individual care plans and risk assessments. People’s risks were assessed and staff had guidance on how to prevent or mitigate these risks, which we saw was being followed. The care plans we looked at were regularly reviewed. However, the people, their relatives and other relevant health professionals were not formally involved in the process of reviewing this information. Some care plans also lacked personalisation, giving staff only very basic information about the people they were supporting.

We saw that there were policies and procedures in place to guide staff in relation to safeguarding vulnerable adults and whistleblowing. Staff had had training on this and information about how to raise safeguarding concerns was readily available in various places throughout the home. Staff told us that they felt people living at the home were safe, as did the people living there and their relatives.

Medication was correctly administered, stored and recorded.

Staff were safely recruited. Criminal records checks, known as Disclosure and Barring Service (DBS) records, were carried out We also saw that official identification, such as a passport or driving licence, and verified references from most recent employers were also kept in staff files. However, the recruitment files we looked at were disorganised and inconsistent. The registered manager confirmed that they were planning to review and improve these files.

We saw that there was a sufficient number of staff on duty to meet people needs. We also observed caring interactions between staff and the people living at the home.

On our last inspection we found that the registered manager, who is a qualified nurse, did not have adequate administrative support and was regularly completing shifts at the home as a nurse. This meant that the registered manager did not have the time or support to ensure the home was well led. On this inspection we saw that changes had been made in this area, as the registered manager had a full-time administrator and they no longer worked regular shifts as a nurse at the home.

Waverley Care Home is located near to Sefton Park Liverpool and is close to local amenities such as cafes, restaurants, shops and public transport links. There is on street parking and a garden to the rear of the property. It provides residential and nursing care for up to 20 people; some people lived with dementia or enduring mental health needs. At the time of our inspection, there were 13 people living in the home.

At our inspection on 19 August 2015, we found that there were breaches of Regulations 11,12,15 and 17 of the Health and Social Care Act 20108. These related to consent, medication administration, premises and equipment and good governance. When we re-visited on 23 March 2016, we found that progress had been made and believed that this progress would continue. However, at this inspection we found that insufficient progress had been made and the provider was not meeting the requirements of the Regulations. You can see what action we told the provider to take at the back of the full version of the report.

The service required a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The home had a registered manager who had been in post for just over a year, at the time of our inspection.

Some people had not been appropriately assessed or regard taken of their cultural and language needs. This meant that the person was unable to communicate little with other people and had to conform to western styles of eating.

The care plans we looked at gave details of people’s medical history and medication and information about the person’s life and their preferences. People were all registered with a local GP and records showed that people saw a GP, dentist, optician, and chiropodist as needed. Some information in the care plans however was not clear and the records were difficult to follow.

The provider had partly complied with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and its associated codes of practice in the delivery of care. This was because a person’s communication needs had not been met and therefore an assessment of their mental capacity or a best interest meeting might not be a fair representation of the person’s ability to make decisions. Staff we spoke with had minimal understanding of what this meant or what their obligations were in order to maintain people’s rights. Some people were deprived of their liberty unlawfully because they did not have free access to leave or re-enter the home.

People who used services were not protected from unsafe care because of poor staff recruitment checks, inadequate staffing levels, the lack of robust and regular risk assessments and inadequate checks related to the safety of the premise’s. People were not cared for by suitable and appropriately trained staff. People told us they felt safe with staff and this was confirmed by the relatives we spoke with

People received sufficient quantities of food and drink and had a choice in the meals that they received. Menus were flexible and alternatives were provided for anyone who didn’t want to have the meal on the menu for that day. People we spoke with said they always had plenty to eat. However, mealtimes were set and drinks available only at certain times in the day. This meant that they could not access food or drinks other than water, when they wanted to.

The staffing levels were seen to be insufficient at times to support people and meet their needs, especially in relation to activities during the day. We observed that some staff did not interact or talk with people through much of the time we were in the home.

Some risk assessments had being revised, but some were very out of date. Accident and incident reporting was poor.

The medication storage and administration was appropriate and we found the stocks of medication tallied with the records.

There had been an administrator in the home who had left the service about six months previously. The registered manager was often busy performing the role of registered nurse in the home and records showed that there had been few meaningful audits of the service to ensure quality. Other records were haphazard and difficult to follow. This meant that the systems in place to identify and mitigate risks to people’s, health, safety and welfare, were ineffective.

People said the home was "lovely" and that the staff were "great". We saw staff interact with service users throughout the day. Some people were able to leave the home independently to go to local shops and others needed more support and assistance.

People were able to chose which they activities they took part in. Relatives told us, and we saw, that they joined with people using the service going out for lunch locally. Some people said that they did not like to go out and that although staff encouraged them to do things, they were always free to choose.

We saw that risk assessments were carried out appropriately and care for people using the service was planned and agreed. Staff had received training about safeguarding vulnerable people from abuse and were able to discuss this.

The property was maintained adequately and was secure. Repairs were dealt with promptly. People said they felt safe during the day and at night.

We saw relevant policy and procedure documents which were up to date. We saw that regular surveys and audits took place to monitor the quality of the service provided at the home.